Case Study: Symptomatic, Progressing mCRPC

Patient Case 4:

• A 70-year-old white male, PSA 5.7 PMH: (+) FH CaP, HTN,? h/o seizures, EtOH; DRE: BPH, no nodules, induration
• Apr2007: 14/18 cores (+), Gleason 4 + 4, 4 + 5, gland 45 grams Bone scan, CT scan negative
• Jul 2007: XRT/ADT Dec 2007: PSA 0.4 ng/ml Jul 2008: PSA 0.8 ng/ml Nov 2008: PSA 4.2 ng/ml, test 19 July 2009: PSA 6.8 ng/ml Nov 2009: PSA 14.2 ng/ml
• Dec 2009: Clinical trial, ADT (monthly for 1 year) CT/Bone scan (—) On study, PSA remain <0.1 ng/ml
• Mar 2011: PSA 0.31 ng/ml
• Mar 2012: PSA 2.8 ng/ml
• Jul 2012: PSA 3.3 ng/ml
• Oct 2012: PSA 6.3 ng/ml
• Dec 2012: PSA 9.8 ng/ml Bone/CT scans: (+) multiple bone mets, (—) soft tissue ECOG: 1

Several therapies are now available for the treatment of patients wtih metastatic castration-resistant prostate cancer (mCRPC). However, without molecular markers to guide choice of therapy, physicians are faced with the decision of which to use and in what order.

The patient in this case-based discussion is one who will probably receive all available agents at some point. He is a 70-year-old Caucasian who presented in 2007 with a PSA level of 5.7 and family history of prostate cancer, hypertension, possible seizures, and regular alcohol use. He was diagnosed with high-grade prostate cancer and was subsequently treated with radiation therapy and androgen deprivation therapy (ADT). His PSA level continued to rise and in 2009 he was enrolled in a clinical trial of ADT, which stabilized the PSA at 0.1.

However, in 2011 his PSA began to rise rapidly and at the end of 2012, imaging showed multiple bone metastases, but no soft-tissue disease. At that time, he developed symptoms of bone pain that required opiates for relief. This is a classic case of a symptomatic metastatic patient for whom upfront docetaxel is appropriate, says Daniel Petrylak, MD.

Following a strong response to docetaxel, in the post-chemotherapy space there are a number of options. At this point, a wealth of options are available to patients, including abiraterone acetate, enzalutamide, and radium-223. The next therapy should be customized based on patient characteristics. In this patient, given the lack of soft tissue metastases, radium-223 is a reasonable option, notes Celestia S. Higano, MD. Additionally, as a result of a prior history of seizures, the patient is not eligible for enzalutamide, the panel agrees.